To What Degree Can We Trust What We're Taught In Medical School...?

Many of the books we use and the articles we base our practices on are produced by academic physicians and PhDs who have a variety of conflicting interests. They range from the allocation of public health dollars to issue advocacy. So to what degree can we actually trust that what we are taught to do in medical school is training us to actually safeguard the one interest that Hippocrates held sacred: the well being of the individual we are treating at a given point in time?

I ask this question as I ponder the increasing intrusiveness of "it costs this much to do this" and "outcomes measured in dollars per patient life year" into medical education.

I also ask it as, moving through my clinical years, I've seen a series of middle aged doctors play the odds in clinical practice...with no goal other than to see if they could "get away" without ordering particular tests or imaging studies. Sometimes they got away with it. Other times they ended up ordering them after a delay that caused the patient in question extra pain, suffering, or a delayed cure without permanent harm. Occasionally it has even resulted in a patient's demise (usually in the internal medicine setting).

I have half a mind to go out and buy a set of 20 or 30 year old textbooks of medicine when I'm done to get the perspective of those who came before us whose clinical reasoning may not have been tainted by such extraneous concerns.

I also ask it as, moving through my clinical years, I've seen a series of middle aged doctors play the odds in clinical practice...with no goal other than to see if they could "get away" without ordering particular tests or imaging studies. Sometimes they got away with it. Other times they ended up ordering them after a delay that caused the patient in question extra pain, suffering, or a delayed cure without permanent harm. Occasionally it has even resulted in a patient's demise (usually in the internal medicine setting).

I hear what you're saying. In general... you should take everything you are taught with a grain of salt. There is very little in Medicine that is absolute. However.... that has, and will continue to be the case well beyond our time as physicians. Read and listen and do... after which... you may begin to understand. Understanding takes time... years at least to develop any meaningful comprehension of the field. Once you begin to grasp it... you end up realizing that only the foundation stays solid (at least you hope), with everything you have built upon the foundation being capable of collapse. With that said... every physician has his/ her own way of dealing with the various uncertainties. Debating to perform any imaging/ procedure is a consequence of these uncertainties. Yes.. there will always be 'weak' physicians... but keep in mind that questioning every order in terms of its potential affect on patient care is critical... and necessary to stay sharp.

I also ask it as, moving through my clinical years, I've seen a series of middle aged doctors play the odds in clinical practice...with no goal other than to see if they could "get away" without ordering particular tests or imaging studies. Sometimes they got away with it. Other times they ended up ordering them after a delay that caused the patient in question extra pain, suffering, or a delayed cure without permanent harm. Occasionally it has even resulted in a patient's demise (usually in the internal medicine setting).

Most discussions about the rising cost of health care emphasize the need to get more people insured. The assumption seems to be that insurance  rather than the service delivered by doctor to patient  is the important commodity.
But perhaps the solution to much of what currently plagues us in health care  rising costs and bureaucracy, diminishing levels of service  rests on a radically different approach: fewer people insured.
You don't need to be an economist to understand that any middleman interposed between seller and buyer raises the price of a given service or product. Some intermediaries justify this by providing benefits, such as salesmanship, advertising or transport. Others offer physical facilities, such as warehouses. A third group, organized crime, utilizes fear and intimidation to muscle its way into the provider-consumer chain, raking in hefty profits and bloating cost, without providing any benefit at all.
The health insurance model is closest to the parasitic relationship imposed by the Mafia and the like. Insurance companies provide nothing other than an ambiguous, shifty notion of "protection." But even the Mafia doesn't stick its nose into the process; once the monthly skim is set, Don Whoever stays out of the picture, but for occasional "cost of doing business" increases. When insurance companies insinuate themselves into the system, their first step is figuring out how to increase the skim by harming the people they are allegedly protecting through reduced service.
Insurance is all about betting against negative consequences and the insurance business model is unique in that profits depend upon goods and services not being provided. Using actuarial tables, insurers place their bets. Sometimes even the canniest MIT grads can't help: Property and casualty insurers have collapsed in the wake of natural disasters.
Health insurers have taken steps to avoid that level of surprise: Once they affix themselves to the host  in this case dual hosts, both doctor and patient  they systematically suck the lifeblood out of the supply chain with obstructive strategies. For that reason, the consequences of any insurance-based health-care model, be it privately run, or a government entitlement, are painfully easy to predict. There will be progressively draconian rationing using denial of authorization and steadily rising co-payments on the patient end; massive paperwork and other bureaucratic hurdles, and steadily diminishing fee-recovery on the doctor end.
Some of us are old enough to remember visiting the doctor and paying him/her directly by check or cash. You had a pretty good idea going in what the service was going to cost. And because the doctor had to look you in the eye  and didn't need to share a rising chunk of his profits with an insurer  the cost was likely to be reasonable. The same went for hospitals: no $20 aspirins due to insurance-company delay tactics and other shenanigans. Few physicians became millionaires, but they lived comfortably, took responsibility for their own business model, and enjoyed their work more.
Several years ago, I suffered a sports injury that necessitated an MRI. The "fee" for a 20-minute procedure was over $3,000. My insurance company refused to pay, so I informed the radiologist that I'd be footing the bill myself. Immediately, the "fee" was cut by two thirds. And the doctor was tickled to get it.
A few highly technical and complex procedures that need to amortize the purchase of extremely expensive hardware will be out of reach for any but the wealthiest patient. For that extremely limited category, insurance might work. A small percentage of indigent individuals won't be able to afford even low-cost procedures. For them, government-funded county facilities are the answer, because any decent society takes care of the weakest among us. But a hefty proportion of health-care services  office visits, minor surgeries  would be affordable to most Americans if the slice of the health-care dollar that currently ends up in the coffers of insurance companies was eliminated.
When I was in practice as a psychologist, I discussed fees up front with prospective patients, prior to their initial visit. People appreciated knowing what to expect and my bad debt rate was less than 1%. That allowed me to keep my charges reasonable and, on occasion, to lower them for less fortunate patients. And I loved my job because I was free to concentrate on what I went to school for: helping people, rather than filling out incomprehensible forms designed to discourage me from filing them in the first place.
Physicians and other providers need to liberate themselves from the Faustian bargain they've cut with the Mephistophelian suits who now run their professional lives. Because many doctors are loath to talk about money, they allowed themselves to perpetuate the fantasy that "insurance is paying." It isn't. There is no free lunch and no free physical exam.
If substantial numbers of health-care providers shook off the insurance monkey on their back, en masse, and the supply of providers was substantially increased by opening more medical schools, the result would be a more honest, cost-effective system benefiting everyone. Except the insurance companies.Dr. Kellerman, clinical professor of pediatrics and psychology at USC's Keck School of Medicine, is the author of numerous crime novels and three books on psychology. His latest novel is "Compulsion" (Ballantine, 2008).

Sorry; been studying for a shelf. Example? Well, how about this from Lange's Family Medicine regarding diabetic foot ulcers...

"Becaplermin (Regranex) aids in healing, but it is expensive and usually not necessary."

Translanted into plainspeak, that to me reads "Well guys, while Regranex actually does help, it's plenty expensive and since most of these people aren't going to go on to develop osteomyelitis or have an amputation without it, we at Metropolis Insurance prefer you didn't use it."

Sorry; been studying for a shelf. Example? Well, how about this from Lange's Family Medicine regarding diabetic foot ulcers...

"Becaplermin (Regranex) aids in healing, but it is expensive and usually not necessary."

Translanted into plainspeak, that to me reads "Well guys, while Regranex actually does help, it's plenty expensive and since most of these people aren't going to go on to develop osteomyelitis or have an amputation without it, we at Metropolis Insurance prefer you didn't use it."

Many of the books we use and the articles we base our practices on are produced by academic physicians and PhDs who have a variety of conflicting interests. They range from the allocation of public health dollars to issue advocacy. So to what degree can we actually trust that what we are taught to do in medical school is training us to actually safeguard the one interest that Hippocrates held sacred: the well being of the individual we are treating at a given point in time?

I ask this question as I ponder the increasing intrusiveness of "it costs this much to do this" and "outcomes measured in dollars per patient life year" into medical education.

I also ask it as, moving through my clinical years, I've seen a series of middle aged doctors play the odds in clinical practice...with no goal other than to see if they could "get away" without ordering particular tests or imaging studies. Sometimes they got away with it. Other times they ended up ordering them after a delay that caused the patient in question extra pain, suffering, or a delayed cure without permanent harm. Occasionally it has even resulted in a patient's demise (usually in the internal medicine setting).

I have half a mind to go out and buy a set of 20 or 30 year old textbooks of medicine when I'm done to get the perspective of those who came before us whose clinical reasoning may not have been tainted by such extraneous concerns.

I didn't go to medical school to become some HMO's hatchet man.

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whatever the hot little drug reps with free dinners tell you is the truth

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